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My counseling takes place in Manhattan
(New York County), where, in 2008, 23 insurance organizations offer 28 HMOs (including nine without
prescription drugs), 6 POSs (including 1 without prescription drugs), 9
PPOs (including 2 without prescription drugs) and 21 PFFSs (including 9
without prescription drugs). In
addition, there are thirty-nine special needs plans for persons who are
dual eligible for Medicare and Full Medicaid (29 plans), people in
long-term care facilities (7 plans) and people with certain chronic or
disabling conditions (3 plans). And to round out this voluminous
package, there are also two Medical Savings Account Plans and one
PSO. They add up to a grand
total of 106 Private Plans. And
I can add that the other four counties in New York City have similar,
wide-open opportunities.
I have completed my annual analysis (started in 2005) of
the HMO/PPO “scene.”
Hopefully, the following snapshots (*) will be helpful in making HMO and PPO plan selections
less complicated.
*You should
obtain a current listing of available plans (HMOs may close enrollment
because of capacity limits) from medicare.gov, to insure that you
don’ miss out on any that might be of interest to you. And most importantly, you will have
available an outline of costs and benefits of the individual plans.
*As mentioned in my
introduction, there are Special Needs Medicare Advantage plans (SNP)
for beneficiaries who have full Medicaid, live in institutions or have
chronic or disabling conditions.
Two main questions need to be answered by a Medicare-Medicaid
person considering SNP. Will the
State pay for the cost sharing for Medicare covered services? Will the choice of doctors in the
Medicare Advantage SNP be a better match for his/her needs?
*I have found that HMOs and PPOs
offer variations in cost sharing and access to benefits that are
difficult to distinguish – a continuation of 2007.
*PPOs have
brought into full focus for Medicare beneficiaries a new concept in
cost sharing. Medicare
beneficiaries are accustomed to being charged deductibles, co-payments
and co-insurance percentage of the approved charge (in the Medicare fee
schedule). And now, as PPO
members, if you choose the option of going outside the network of
preferred health care providers for service, you will be charged by the
medical provider a co-insurance percentage of the cost of the service
or product – for example, 80% payment by the insurance company
and 20% of the cost by the beneficiaries. But how do you anticipate your
cost, when you don’t know,
for example, what was charged the PPO by the hospital for the
in-patient visit, by the skilled nursing facility or durable equipment
vendor? An analysis of the seven
PPOs (with prescription drugs) shows five charging 20%/25%/30%/50% of
cost to members going to outside network providers for approximately 72% and
more of their medical services (2-97%, 2-86% and 1-72%).
*Two of the
above PPOs had not-to-exceed $1500 limits for each inpatient hospital and
mental stay, and one PPO has a $1500 limit for each inpatient mental
stay and a $2000 annual limit for inpatient hospital. The two remaining PPOs billing 97% of
outside of network providers @ 30% of cost has a not-to-exceed $3500
limit for certain services in one PPO and a $5000 not-to-exceed limit
in the other PPO. Additionally
one has a $500 annual deductible and the other has a $1000 annual
deductible. You have to contact the plan for the applicable services for
the last two not-to-exceed limits and the two deductibles.
*The two PPOs,
rounding out the seven, have more of the favorable co-payment terms for
outside network providers – for approximately 47% of the services
in one PPO and 73% of the services in the other. There is a not to exceed limit of
$2800 in the first PPO and you need to contact the plan for the
applicable services.
*I think it is
fair to say that if you are involved with outside of network providers
in most of the reviewed PPOs, you may end up paying more than an
Original Medicare and Medigap subscriber. There is no way of predicting how
much more – you know the “percentage” you must pay of
the cost charged by the provider, but we are not given the amount of
cost.
And let us now continue with cost
sharing and access to benefits for HMOs.
*The billing of
(co-insurance) % of cost of a service to the insured member continues
to be used in HMOs instead of the usual co-payment. My count shows 26 HMOs out of 28
using this method –23 for 1 through 4 services, 2 for five, and
one for 11 services. The
percentage of plans using this method increased 16% over last year, the
third year in a row of increases year over year.
*I discovered in 2007 a new mystery
in HMO cost sharing. Primary
doctor and specialist rates were always specific. Not anymore – 75% of HMOs
stated the following: You may
have to pay separate co-pays for certain doctor office visits. This uncertainty will continue in
2008, but to a lesser extent – 68% of HMOs instead of the
previous year’s 75% -- but “not knowing” doctor
co-pays still continues for a significant percentage of HMOs.
The following HMO cost
information needs to be given in tandem:
*Only four of
28 HMOs charge a monthly premium (2 @ $24.10, $85 and $60). And twenty HMOs charge for hospital
visits – 2 stays of $150/300, 17 with co-payment schedules
($40-250) from 1-5 days to 1-20 days and one HMO follows the standard
Medicare Part A deductible and daily co-payment schedule.
Access to benefits is not
clearly defined, which can cause big problems for beneficiaries. For example:
*HMO
organizations state in their plans: “You must go to network
doctors, specialists and hospitals.” Referral not required to seeing a
physician specialist.” And
they go on to state the following:
*Referrals are
required for specialists for certain
benefits. Therefore,
subscribers in 11 plans with this rule (out of possible 28 HMO plans)
will be wondering whether they need a referral for their chosen
specialist – more uncertainty
*Or “authorizations
rules may apply” – to nine to fourteen sets of services
(out of approximately 30) among each of 15 plans; and in the remaining
plans’ sets of services, there are five plans with five or six
authorization rules, one plan with 24 and seven plans with one
each. The possibility that the
insurance plan reserves the right to countermand the order (that has
been based on the physician’s diagnosis code) of your internist
or specialist, may jeopardize your ready access to health care.
*And to top
this off, you are warned in many of the HMO brochures: “The
health providers in our network can change at any time.” Therefore, I suggest that you check
your prospective medical provider visit with your insurance company for
the following: Is the provider a network provider? Is a referral needed? Is
authorization from the HMO needed?
I believe all
of these Medicare Advantage snapshots give us a picture of multiple
variations which are difficult to distinguish – thus making it
difficult to evaluate a prudent plan choice. I haven’t seen it so complex in
16 years of volunteer counseling.
The total “picture” cries out for standardization
and transparency. So what to
do? First, focus on the doctor(s) you are using or will be using. Go to the plans where those doctors
can be found. This will narrow
the search for choice of plan – then examine the provisions very
carefully, keeping in mind the possible
trouble spots. Please remember
that HMOs and PPOs are not the diagnosticians – doctors are. This is the counseling advice I have
given over the years. I
addressed this topic in fuller detail in the previous segment. And if the search for the plan is
still difficult, seek one-on-one counseling. Medicare segment 09 will offer details.
Updated: January 4, 2008
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